Systemic antibiotics for symptomatic apical periodontitis and acute apical abscess in adults

Cope, Anwen ORCID: https://orcid.org/0000-0003-3721-9455, Francis, Nicholas ORCID: https://orcid.org/0000-0001-8939-7312, Wood, Fiona ORCID: https://orcid.org/0000-0001-7397-4074, Thompson, Wendy and Chestnutt, Ivor ORCID: https://orcid.org/0000-0002-9228-800X 2024. Systemic antibiotics for symptomatic apical periodontitis and acute apical abscess in adults. Cochrane Database of Systematic Reviews 10.1002/14651858.CD010136.pub4 Item availability restricted.

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Abstract

Background Dental pain can have a detrimental effect on quality of life. Symptomatic apical periodontitis and acute apical abscess are common causes of dental pain and arise from an inflamed or necrotic dental pulp, or infection of the pulpless root canal system. Clinical guidelines recommend that the first-line treatment for these conditions should be removal of the source of inflammation or infection by local, operative measures, and that systemic antibiotics are currently only recommended for situations where there is evidence of spreading infection (cellulitis, lymph node involvement, diffuse swelling) or systemic involvement (fever, malaise). Despite this, there is evidence that dentists frequently prescribe antibiotics in the absence of these signs. There is concern that this could contribute to the development of antibiotic-resistant bacteria. This review is the second update of the original version that was published in 2014. Objectives To evaluate the effects of systemic antibiotics provided with or without surgical intervention (such as extraction, incision and drainage of a swelling, or endodontic treatment), with or without analgesics, for symptomatic apical periodontitis and acute apical abscess in adults. Search methods We searched the following databases: Cochrane Oral Health's Trials Register (to 26 February 2018 (discontinued)), the Cochrane Central Register of Controlled Trials (CENTRAL; 2022, Issue 10) in the Cochrane Library (searched 25 November 2022), MEDLINE Ovid (1946 to 23 November 2022), Embase Ovid (1980 to 23 November 2022), and CINAHL EBSCO (1937 to 25 November 2022). The US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials (25 November 2022). A grey literature search was conducted using OpenGrey (to 26 February 2018 (discontinued)), ZETOC Conference Proceedings (1993 to 26 February 2018 (discontinued)) and ProQuest Dissertations & Theses Global (to 25 November 2022). No restrictions were placed on the language or date of publication. Selection criteria Randomised controlled trials of systemic antibiotics in adults with a clinical diagnosis of symptomatic apical periodontitis or acute apical abscess, with or without surgical intervention (considered in this situation to be extraction, incision and drainage or endodontic treatment) and with or without analgesics. Data collection and analysis Two authors screened the results of the searches against inclusion criteria, extracted data and assessed risk of bias independently and in duplicate. A fixed-effect model was used in the meta-analysis as there were fewer than four studies. We contacted study authors to obtain missing information. We used GRADE criteria to assess the certainty of the evidence. Main results There was one new completed trial on this topic since the last update in 2018. In total three trials and 134 participants were included. Objective 1: systemic antibiotics versus placebo with surgical intervention and analgesics for symptomatic apical periodontitis or acute apical abscess One trial (72 participants) compared the effects of a single preoperative dose of clindamycin versus a matched placebo when provided with a surgical intervention (endodontic chemo-mechanical debridement and filling) and analgesics to adults with symptomatic apical periodontitis. We assessed this study as having low risk of bias. There were no differences in participant-reported pain or swelling across trial arms, at any of the time points assessed. The median values for pain (numerical scale 0 to 10) were 3.0 in both groups at 24 hours (p=0.219); 1.0 in the antibiotic group vs. 2.0 in the control group at 48 hours (p=0.242); and 0 in both groups at 72 hours and 7 days respectively (p=0.116 and 0.673). The relative risk of swelling when preoperative antibiotic is compared to placebo is 0.50 (95% CI 0.10 to 2.56, p=0.41). The quality of evidence for all the outcomes in this comparison was judged to be low. Two trials (62 participants) compared the effects of 7 days course of oral phenoxymethylpenicillin (penicillin VK) versus a matched placebo when provided with a surgical intervention (total or partial endodontic chemo-mechanical debridement) and analgesics to adults with acute apical abscess or symptomatic necrotic tooth. Participants in both trials also received oral analgesics. We assessed one study as having a high risk of bias and the other as having unclear risk of bias. There were no differences in participant-reported measures of pain or swelling at any of the time points assessed within the review. The MD for pain (short ordinal numerical scale 0 to 3) was -0.03 (95% CI -0.53 to 0.47) at 24 hours; 0.32 (95% CI -0.22 to 0.86) at 48 hours; and 0.08 (95% CI -0.38 to 0.54) at 72 hours. The SMD for swelling was 0.27 (95% CI -0.23 to 0.78) at 24 hours; 0.04 (95% CI -0.47 to 0.55) at 48 hours; and 0.02 (95% CI -0.49 to 0.52) at 72 hours. The quality of evidence for all the outcomes in this comparison was judged to be very low. Adverse effects, as reported in two studies, were diarrhoea (one participant, placebo group), fatigue and reduced energy post-operatively (one participant, antibiotic group) and dizziness pre-operatively (one participant, antibiotic group). Objective 2: systemic antibiotics without surgical intervention for adults with symptomatic apical periodontitis or acute apical abscess We found no studies that compared the effects of systemic antibiotics with a matched placebo delivered without a surgical intervention for symptomatic apical periodontitis or acute apical abscess in adults. Authors' conclusions The evidence suggests that preoperative clindamycin for adults with symptomatic apical periodontitis results in little to no difference in participant-reported pain or swelling at any of the time points included in this review when provided with chemo-mechanical endodontic debridement and filling under local anaesthesia. The evidence is very uncertain about the effect of post-operative phenoxymethylpenicillin for adults with localised apical abscess or a symptomatic necrotic tooth when provided with chemo-mechnical debridement and oral analgesics. There were no studies identified which compared the effects of systemic antibiotics with a matched placebo delivered without a surgical intervention for symptomatic apical periodontitis or acute apical abscess in adults.

Item Type:	Article
Date Type:	Published Online
Status:	In Press
Schools:	Dentistry Medicine
Subjects:	R Medicine > RK Dentistry
Publisher:	Cochrane Collaboration
ISSN:	1469-493X
Date of First Compliant Deposit:	1 March 2024
Date of Acceptance:	27 February 2024
Last Modified:	01 May 2024 11:56
URI:	https://orca.cardiff.ac.uk/id/eprint/166766

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